Digitally mediated psychotherapy: Intimacy, distance, and connection in virtual therapeutic spaces

ABSTRACT

This paper is a commentary on the articles in this Technology, AI Bots and Psychology Special Issue. The Special Issue presents a range of conceptual, practice-based and empirical reflections on digitally mediated therapy. This includes looking back to a significant shift in digital engagement due to the COVID-19 pandemic, along with anticipations regarding the landscape of future therapeutic practices mediated by digital technologies. I will discuss key themes resonating across the Special Issue, along with attending to some of the nuance and diversity of the potential and real implications of a greater integration of digital technologies in current and future therapeutic practice.

ABSTRAKT

Dieses Papier ist ein Kommentar zu den Artikeln in dieser Sonderausgabe zu Technologie, KI-Bots und Psychologie. Das Sonderheft präsentiert eine Reihe konzeptioneller, praxisbezogener und empirischer Überlegungen zu digital vermittelte Therapie. Dazu gehört auch der Rückblick auf einen erheblichen Wandel im digitalen Engagement zur Covid-19-Pandemie, zusammen mit Erwartungen hinsichtlich der Landschaft zukünftiger Therapien Praktiken, die durch digitale Technologien vermittelt werden. Ich werde Schlüsselthemen besprechen, die im gesamten Special eine Rolle spielen Problem, zusammen mit der Berücksichtigung einiger der Nuancen und Vielfalt des Potenzials und der Realität und die Auswirkungen einer stärkeren Integration digitaler Technologien in aktuelle und zukünftige Therapien ausüben.

RESUMEN

Este artículo es un comentario sobre los artículos de este número especial de Tecnología, Bots de IA y Psicología. El número especial presenta una serie de reflexiones conceptuales, prácticas y empíricas sobre la terapia mediada digitalmente. Esto incluye mirar hacia atrás a un cambio significativo en el compromiso digital debido a la pandemia de Covid-19, junto con anticipaciones sobre el panorama de futuras prácticas terapéuticas mediadas por tecnologías digitales. Discutiré temas clave que resuenan en el número especial, además de atender algunos de los matices y la diversidad de las implicaciones potenciales y reales de una mayor integración de las tecnologías digitales en la práctica terapéutica presente y futuro.

ABSTRAIT

Cet article est un commentaire sur les articles de ce numéro spécial sur la technologie, les robots IA et la psychologie. Le numéro spécial présente une gamme de réflexions conceptuelles, pratiques et empiriques sur la thérapie à médiation numérique. Cela implique de revenir sur un changement important dans l’engagement numérique dû à la pandémie de Covid-19, ainsi que sur les anticipations concernant le paysage des futures pratiques thérapeutiques médiées par les technologies numériques. J’aborderai les thèmes clés qui résonnent dans ce numéro spécial, tout en m’attardant sur certaines des nuances et de la diversité des implications potentielles et réelles d’une plus grande intégration des technologies numériques dans la pratique thérapeutique actuelle et future.

ΠΕΡΊΛΗΨΗ

Η παρούσα εργασία αποτελεί σχολιασμό των άρθρων του παρόντος ειδικού τεύχους σχετικά με την Τεχνολογία, την Τεχνητή Νοημοσύνη και την Ψυχολογία. Το ειδικό τεύχος παρουσιάζει ένα φάσμα εννοιολογικών, πρακτικών και εμπειρικών προβληματισμών σχετικά με τη θεραπεία με ψηφιακή διαμεσολάβηση. Αυτό περιλαμβάνει την αναδρομή σε μια σημαντική αλλαγή στην ψηφιακή εμπλοκή λόγω της πανδημίας Covid-19, μαζί με προβλέψεις σχετικά με το τοπίο των μελλοντικών θεραπευτικών πρακτικών που διαμεσολαβούνται από ψηφιακές τεχνολογίες. Θα συζητήσω τα βασικά θέματα που έχουν απήχηση σε όλο το ειδικό τεύχος, παράλληλα με την εστίαση σε ορισμένες από τις αποχρώσεις και την ποικιλομορφία των πιθανών και πραγματικών συνεπειών μιας μεγαλύτερης ενσωμάτωσης των ψηφιακών τεχνολογιών στην τρέχουσα και μελλοντική θεραπευτική πρακτική.

KEYWORDS:

• Digital psychotherapy
• Intimacy
• Connection
• distance
• mediation

SCHLÜSSELWÖRTER:

• Digitale Psychotherapie
• Intimität
• Verbindung
• Distanz
• Mediation

PALABRAS CLAVE:

• Psicoterapia digital
• Intimidad
• Conexión
• distancia
• mediación

MOTS-CLÉS:

• Psychothérapie numérique
• Intimité
• Connexion
• distance
• médiation

ΛΈΞΕΙΣ-ΚΛΕΙΔΙΆ:

• Ψηφιακή ψυχοθεραπεία
• οικειότητα
• σύνδεση
• απόσταση
• διαμεσολάβηση

Main text

A digitisation of mental health support has been underway for some time (Fullagar et al., 2017; Hollis et al., 2018; Wilson, 2022) and was accelerated following the outbreak of the COVID-19 pandemic (I. Tucker et al., 2023). A necessary choice was quickly presented to psychotherapy during this period, namely whether to undertake therapy online or not at all due to the social distancing rules at the time. Online delivery was not entirely new but was not a mainstream practice in psychotherapy, largely due to questions as to whether effective therapy could be provided through the medium of a screen. It has often been deemed to be problematic to enact the empathic connection central to psychotherapeutic practice online (Agosta, 2022; Békés et al., 2021; Sperandeo et al., 2021).

The ’return to normal’ following the lifting of social distancing regulations led many to return to in-person practice. However, a legacy has emerged of online practice, and there is now a growing body of research investigating its potential. This special issue sets out to explore some of the implications of online therapy and a broader use of digital forms of support including automation of the therapeutic relationship. Papers in the special issue consider digitisation in its multiple forms, from online consultations, online training, perinatel services, through to automated therapists, and included conceptual and empirical insights. In this commentary, I thematise the papers around key insights across the special issue as key to understanding the potential impacts of digital psychotherapy, as well as some of salient points of difference and divergence. As we know, the use of digital and online platforms raises a wide range of difference from in-person settings, and therefore, it is important not to homogenise ‘the digital’ as operating in a single universal way.

There were several resonances from across the papers that are important. Firstly, how online and digital access can improve accessibility, and that this can be valuable, e.g. for people for whom accessing in-person therapy is difficult (e.g. those who experience social anxiety, vulnerable groups such as LGBT+ in prohibitive countries, people living in areas of conflict, people with disability). Increasing access to psychotherapy is a major priority, so the power of online therapy to increase access should not be downplayed. Secondly, that communicating online is different from in-person connections, in several ways. The most obvious is the lack of embodied presence, which changes how non-verbal communication operates. This is not to suggest that non-verbal communication is absent in online therapy, but it is significantly different. Thirdly, that the impact of online therapy is not reducible to the idea that technology in the form of video conferencing software and digital devices is only a tool/means to an end. Instead, we need to attend to the ways that technology transforms behaviour, communication and experience in a more fundamental way. Several of the papers in the special issue pointed to the ways that we become with technology, which has conceptual, empirical and practical implications. For instance, understanding that technologies are not solely passive tools but come to have agency in the relational practices of online therapy. Understanding the agency of technologies and the non-human material world has developed significantly in fields such as Science and Technology Studies, new materialist theory and post-human philosophies (e.g. Hayles, 1999; Latour, 1993; Lupton, 2020). These conceptual contribution of these Finally, we do not know what the future holds for online psychotherapy, but what is evident is that it is here to stay and therefore we need to scrutinise, through research and practice, how to maximise its benefits while minimising the challenges, not all of which are currently known. I will frame my discussion around key notions that came through papers across the special issue, and which relate to key issues facing online therapy, namely embodiment, distance, automation and connection. I will start with embodiment.

The role of the body in online psychotherapy

A key theme that came through the papers was the importance of embodiment in psychotherapy. Online therapy places a screen between therapist and client, which transforms the role and experience of the body in the therapeutic relationship. Firstly, in terms of the likelihood of only the head and shoulders being visible, and secondly, the distance the screen places between bodies. This was discussed in relation to the phenomenological writings of Merleau-Ponty to emphasise how grounded the therapeutic experience is in the lived experience of the body.

In addition to this, it is worth considering what happens to the body online when we consider it as not bounded by the limits of the skin, but instead consider it as porous and operating in an extended sense as emergent from a broader set of potentialized relational processes, only some of which will actualise in any given setting. Here the work of the philosopher of individuation and technology, Gilbert Simondon, is helpful (Keating, 2019; Scott, 2014; Simondon & Adkins, 2020; Tucker, 2021). Simondon prefers the notion of individuation rather than that of the individual, as it speaks to the way that individual bodies emerge from individuating processes that are beyond the flesh and blood body. This is a non-hyleomorphic model as it does not rely on the idea that individual bodies are based on an inherent form, but rather operate as one part of a set of individuating processes. In psychotherapy, it is not therefore a matter of two fixed bodies being connected via the screen, but rather a digital milieu that incorporates several dimensions (client, therapist, physical settings, screen, time and space).

The key for understanding this is to analyse it as a singularity, with multiple elements in play. Part of this analysis is to understand bodies as operating through the movement of information between them, and other objects. Here, information is not understood in the classic information theory sense (as the mechanism for sharing content about bodies/objects between one another) but as the form that individuation takes. This is based on the notion that:

all objects and living beings emit, transmit and receive information – which constitutes the operation of individual and social life. One can think of the photosynthesis process of a plant flowering through receiving the information of sunlight. Or the anxious response of a child when receiving the information of an unexpected and sudden loud noise. In this case, the anxious response acts as information that is transmitted for others to receive, e.g., in the form of parental concern.

(Tucker, 2021, p. 5)

The question for online therapy is how are the ways that information is emitted, transmitted, and received by bodies transformed in online settings? One example is the need to look away from the screen towards the camera to be seen to be looking at the client. This relates to the argument drawing on Whitehead’s concept of prehension in the paper by Daniel Rubinstein,Schrödingers Cat Goes Online; Exploring the psychopathlogy of digital life, as prehension is a fundamentally relational concept regarding how bodies and objects shape each other through patterns of informational interaction. This also featured in the paper Moving-sensing-feeling bodies clamouring for contact in online therapy groups by Billy Desmond when stating ‘“I” is of a self in motion’, and in Gail Simon’s Looking and listening in online therapy paper in terms of framing ‘the therapeutic relationship as a single energy force rather than a number of individuals’. Analysing the singularity as operating as a series of interconnected relational processes is valuable for capturing the flow of emotion and affect that will shape the therapeutic encounter. In Ronen Stilman’s Virtual reality and screen relations in clinical practice paper, this extended to refer to the atmosphere of online therapy when pointing to the distance, materiality and texture of the online space. The concept of atmosphere has featured in affect studies to speak to the non-reductionist and indeterminate operation of affect in shaping our environments (Ash, 2013; Bissell, 2010; Brown et al., 2019; Duff, 2016). This is a concept used in relation to the operation of support in online mental health forums (Tucker & Goodings, 2017).

Another dimension of the embodiment debate that featured in the special issue was the use of virtual reality. This points to the ways that the increased presence of sensory technologies in our lives makes the boundaries between online-offline/virtual-real increasingly blurry. Moreover, the notion that our digital lives/identities are no less ‘real’ than other parts of our lives. The reality is that our lives are multi-dimensional, with an increasing number of digital dimensions (Bollmer, 2018). These are not well understood if relying on a binary real-virtual dichotomy. Stilman’s virtual reality paper interrogated this through the notion of attachment, which can be experienced differently by different age groups. For instance, those who did not grow up with digital technologies can take longer to acclimatise to life online, whereas for digital natives it can be much easier and immediate. Online access can also present specific issues for therapy, e.g. containment online can be difficult when clients are undertaking therapy in spaces occupied by others (e.g. family members, pets).

Digital psychotherapy and smartness

The use of AI and automation featured in the special issue. This is part of the increasing number of ways that we live in smart societies. Halpern and Mitchell (2022) frame this as the smartness mandate, which captures how there is increased pressure in society to adapt to and live in line with the automation pressures of smart technologies. There is a significant push for smart technologies in all areas of life, including in mental health support such as psychotherapy. Automation can operate at multiple levels, from signposting to support, to a fully automated agent taking the place of a human therapist. In their recent book, The Smartness Mandate, Halpern & Mitchell argue that the smartness of technologies create new kinds of relationships with our everyday environments. At a conceptual level, this goes beyond a didactic human body – technology relationship, to consider the broader ecologies in and through which smartness operates.

A key dimension of smartness is the drive to make societies smarter through identifying relations between individuals and population-level data. Smart technologies work through the generation and categorisation of big data, premised on the argument that more data equals better knowledge. In relation to psychotherapy, this would mean collecting data about therapeutic relations through automated agents, for aggregation in the ongoing training of automated therapists (Aafjes-van Doorn et al., 2021; Delgadillo, 2021). The idea being that the automated therapist is in a constant state of improvement (in a sense always in beta mode), the more data generated and aggregated, the smarter it becomes. This is the key argument of the smartness mandate. This means that a smart technology such as an automated psychotherapist would not only operate in terms of aiming to improve a client’s mental health but would be part of a more complex ecology operating as the systematic relating of population-level data to individual user data. This works through a process of value extraction, as Zuboff (2019) has noted with the notion of surplus value (this is something picked up in the Looking and Listening in Online Therapy paper, by Gail Simon, in relation to big data and surveillance capitalism).

Psychotherapy needs to consider what it means for it to become smart in relation to the use of automation. What would ‘smart therapy’ look like? This is in its infancy currently, but efforts to automate psychotherapy will continue (Ellis & Tucker, 2020). Halpern & Mitchell refer to this as part of an epistemology of derivation, which captures the way that smart technologies operate derivatively, which creates surplus value. Moreover, analysis of the potential impacts of automation involves a more expanded and distributed unit of analysis. The factors at play operate beyond the client-therapist relationship and involve the broader system level context through which therapeutic relationships individuate.

This was picked up in the special issue when talking about therapy sessions being interrupted by people walking into the room that clients were undertaking therapy. The AI, Automation and Psychotherapy – a proposed model for losses and gains in the automated therapeutic encounter paper, by Helen Molden, offered a model based on human factors to consider how AI might operate in therapy, from low automation through to full automation. Low automation can operate solely at the level of influencing the content of what a client may bring to therapy, e.g. aspects of their everyday lives that are influenced, knowingly or not, by automation, such as social media. High automation would involve a ‘therapeutic encounter with a fully autonomous AI virtual therapist’ (p. 8). Significant questions are raised in the paper regarding full automation, including whether key elements of the therapeutic relationship can be automated such as empathy, trust, compassion. Also, is it possible to automate processes such as the way a human therapist is trained to look as much for ‘what isn’t there, as much as for what is’ (p. 11). The paper does note possible benefits of automation, such as the view that as ‘human therapists are inevitably not always fully present in the room, perhaps due to compassion fatigue, burn out or just being distracted on a cognitive level. On this position, where the human is displaying a more performative empathy, perhaps the virtual therapist, fully on message and attentional to the needs of the client, offers the more thorough and successful therapeutic outcome for the client?’ (p. 10) There is a lot bound up in this which needs significant unpacking, but it is an interesting provocation, nonetheless.

The impact of smartness in the form of automation raises several questions such as whether AI can sufficiently replicate a therapeutic setting, can it be empathetic? Can that be programmed to a level that has therapeutic value? And if so, should it be pursued, even if the value is less than therapy with a human therapist?

Exploring the vitality of online psychotherapy

A key theme in the special issue was the notion that digital technologies are not mere tools to aid embodied human life but act as vital agents in the constitution and operation of our lives. In the Shaping force of technology in psychotherapy paper, Patricia Talens draws this out from Heidegger’s claim that we do not use technologies to achieve certain goals, but that we ‘become’ through relations with technologies, and that ‘technology is a way of revealing’ (Heidegger & Lovitt, 1977, p. 12). Our everyday lives are increasingly operating through relations with technologies. These are not distinct domains operating independently but form networks of relations that constitute our experiences, as Talens notes when stating in relation to the technique of CBT, ‘it is not the effect of a technique that is of interest here, but more how a technique interacts and co-creates with us’ (p. 12). This is framed as a post-phenomenological approach. In the Looking and listening in online therapy paper this is captured when stating ‘we are part of new techno-human systems in which therapists are not simply using technology but are being changed by it and are changing of it’ (p. 1). Technology exists in a more fundamental way than just being a tool. What does this mean in therapy? One example is how we look in group therapy discussed in the Moving-sensing-feeling bodies clamouring for contact in online therapy groups paper. To be seen to look at clients it is necessary to not look directly at them on the screen but to look directly at the webcam. This feels strange at first as looking at means looking away. It means that for the most part, a therapist is not looking at clients’ faces, which can make it harder to observe their reactions and expressions. Here technology is creating new ways of seeing and new ways of being seen. In relation to listening we need to recognise that listening is a whole-body action, it is not a passive receptive act. We need to learn how to listen with our whole techno-human body.

Practical applications of online therapy

The special issue included empirical analysis that identified practical applications relating to online therapy. For instance, in the Connecting in a remote world: Psychotherapy and counselling students’ experiences of remote teaching and learning paper, Geraldine Sheedy analysed counselling students’ experiences of being taught online during COVID-19 lockdowns. Some unexpected benefits were experienced, such as being online allowing dedicated time for reflection after teaching sessions as students were alone to reflect. However, connections, in different forms, can be difficult to create and maintain online without the proximity of non-verbal communication, such as clear eye contact etc. Overall, students reported a preference for a blended/hybrid learning model, with online being valuable, but only as part of an overall learning experience that includes in-person learning.

In the Virtual parent infant psychotherapy is impactful and accessible for mothers and babies attending a community perinatel service, Adele Greaves et al. offer a mixed-method analysis of virtual parent-infant psychotherapy, with findings from quantitative and qualitative analysis supporting the value of virtual therapy. However, participants reported a challenge in not having a transitional space between home and therapy. This can be a challenge in relation to the immediacy of online access to mental health support. Immediacy can be beneficial in terms of accessibility, but a challenge in terms of providing a transition space to prepare and decompress in advance of and following therapy. The findings also indicated that participants questioned whether the overall value of virtual parent infant psychotherapy meets that of in-person therapy.

Concluding reflections for future research and practice

What is clear from the special issues is that while undertaking therapy online can transform it, in multiple ways, it does not entirely negate its therapeutic value. The papers discussed multiple experiences of undertaking successful online therapy, in some places facilitating modes of engagement for clients that would not be possible in person, e.g. for those with difficulty accessing in-person therapy. There were many challenges, such as changing the dynamic in terms of the potential for non-verbal embodied communication. Of central importance is how one works at distance in terms of being connected by a screen. The connections made possible in online psychotherapy can be topological. This concept featured in the mid-20^th century social psychology of Kurt Lewin (2013). Although Lewin was not focused solely on emotion, the concept of topology speaks to its operation in digitally mediated communication. An example would be how we can feel closer to someone we are communicating with on the other side of the world (e.g. via Zoom) than with our neighbour who is only a few metres away. The point Lewin (and others have made) is that to understand the strength and operation of relations, we do not have to rely on a geometric sense of distance (e.g. physical proximity), but rather a topological connection can better capture their operation. The French philosopher Michel Serres picked this up when talking about the folding of a handkerchief, in terms of how through the act of folding, new connections can be created between previously distant points (Serres & Latour, 1995). Online therapy can be thought to operate topologically, with the screen folding proximal distances into new relations, which can elicit and facilitate valuable emotional connections. Such connections may be different online than in person, but this does not mean that they are without emotional value.

For future research and practice, the papers elicited key questions. For instance, was the transition to online easier in situations where existing in person relationships existed? Could a hybrid model work, e.g. can the benefits of in person being sustained when combined with online sessions? Are new approaches needed to capture the benefits of online therapy? For instance, in the Schrödingers cat goes online; Exploring the psychopathlogy of digital life paper, Rubenstein points to how engaging with online therapy may require therapists to ‘build bridges between different paradigms, such as computational and psychoanalytic frameworks’ (p. 15). Furthermore, there is the question as to who gets to decide what is ’normal’ in terms of ideas that post-Covid, clinical practice would return to normal in terms of being in-person. Should we consider online therapeutic interactions as by definition inferior? Perhaps, it should not be considered a competition between online and in-person? Setting them up against one another may not be a helpful way forward. There is also a need to acknowledge that we are living in a time of big data and the potential for surveillance capitalism (Zuboff, 2019). This means that generating and commodifying data are very big business, which will bring changes regarding data ethics, privacy and digital surveillance that need to be considered in research and practice regarding online psychotherapy.

Finally, it is important to be open to approaches that can capture the co-creative potential and value of online and in-person settings, rather than starting with a deficit model approach. We need to recognise that regulation and ethical frameworks are lagging in relation to online therapy, and work to support their development to ensure safe and secure therapeutic settings online and in-person. Digital/online access is here to stay so we need to understand its possibilities and limitations.

Disclosure Statement

No potential conflict of interest was reported by the author.

Additional information

Notes on contributors

Ian Tucker

Ian Tucker is Professor of Health and Social Psychology at The University of East London. Ian’s research interests include mental health, emotion and affect, digital media and surveillance. He has published empirical and theoretical work on care and recovery in a range of environments for mental health support; digital peer support in mental health and surveillance. Ian is currently working on a UKRI MARCH Network+ project exploring the impact of digital platforms in relation to ‘community assets’ (e.g. arts and creative communities) and experiences of mental ill-health. Ian is co-author of Social Psychology of Emotion (Sage) and ‘Emotion in the Digital Age’ (Routledge’s Studies in Science, Technology & Society Series).